Classically, eruption of circumscribed, and confluent, reddish, silvery-scaled
maculopapules; the lesions occur predominantly on the elbows, knees, scalp,
and trunk. Common and often severe for HIV patients. ("...Psoriasis in AIDS is most pronounced at intermediate
levels of immunodeficiency, and is diminished or lost in terminal profound immunodeficiency…
" Oxford's textbook citation) Pruritus is not systematic associated but
common in severe psoriasis. It is sometimes possible to observe "circles"
of "pseudo vesicles" (pxx067).
It looks like Tinea but Tinea treatment is useless

CLINICAL APPEARANCES OF PSORIASIS

(Texts
of right column are extracted from Oxford textbook and adapted for our
needs/feeling)

The skin looks as though it has been splashed by the psoriasis.
It often follows a streptococcal sore throat. The lesions are scattered
over the entire body and tend to be no more than a few millimeters in
diameter. They may include the face and are often red slightly scaly
spots. They appear less well defined and less obviously covered
by silvery scales than in classic types of psoriasis.

Palmar and plantar psoriasis

This may be typical of lesions elsewhere but there is often a modification
of the psoriasis due to the nature of the palmer and plantar skin.
The scales tend to be more adherent and less silvery and they are more
likely to develop deep cracks because of the thickness of the epidermis
at these sites. Neutrophils tend to collect into larger abscesses
trapped by the thicker surface layers of the stratum corneum. The
sterile pustules so formed are often the most obvious feature. This
pattern may be seen as part of a more generalized disease but in many
cases it affects only the hands and feet.

Pinpoint pitting is usual but can be seen in other disorders affecting
nail growth. Onycholysis with a salmon-pink discoloration of the
base of the uplift of the nail is probably even more characteristic.
Sometimes the nail growth is distorted, thickened and friable, and difficult
to distinguish from a fungus disorder affecting the nail... For Onychomycosis
see "30-onychomycosis"

This may present as a medical emergency due to fluid loss, septicemia,
or loss of body temperature. Oedema is a consequence of capillary
leak, low albumin, and heart failure. // pxx022-
pxx023//
pxx241//
Generalized redness, the well-defined margins are lost and the scales
are exfoliated profusely. The erythrodermic psoriasis may be indistinguishable
from Erythroderma.
When the normal protective function of the skin is lost, bacteriemia is
common. The loss of water is difficult to estimate and prerenal
failure can develop very rapidly. The vasodilatation and the obstruction
to the sweat ducts by the proliferating epidermis results in impaired
thermoregulation. Hyperthermia is very common in hot climates; hypothermia
can occur in cold climates. Internal organs such as the gut and
liver may be impaired and loss of protein both from the skin and the gut
is an important complication.

Psoriatic arthritis is a severe deforming arthritis involving the multiple
small joints of the hands and feet and spine. The hips, cervical,
and sacroiliac joints are frequently affected and a complete ankylosing
type of spondylitis can occur.

In this condition, which is relatively rare, myriads of pustules quickly
develop and equally quickly disappear. This disorder may occur in
the absence of a previous history of psoriasis and even occasionally as
a viral exanthema. However, most commonly it is only a complication
of psoriasis that has been treated by systemic or local steroids.
It is an acute rebound phenomenon of steroid withdrawal.

Treatment

Vaseline/clotrimazole/betamethasone cream (clotrimazole
is to avoid secondary mycotic infection with chronic use of topic corticoids)
or topical coal tar derivative and/or topical vitamin E derivative or other "traditional
medicines" all may be effective, but if serious generalized condition or
the classic generalized erythrodermic psoriasis
(pxx025...) an intensive course of 4-5 days of high dose dexamethasone has impressive results! (IM 4cc morning
+ 2cc midday, add fluconazole 150mg daily during
the treatment for prevention of fungal infections)

It is important to know that some allergic problems will induce the first eruption
of generalized psoriasis. (See also "6-Allergy")

In case of pustular psoriasis (rare) go slowly in reducing dexa... pustular
psoriasis can be a symptom of dexa withdrawal syndrome... Here we can
make distinction between "normal" doctors and "artist of medical
practice"! Good luck!

It is often impossible to make clinically a differential diagnosis
between "erythrodermic psoriasis" and "acquired erythroderma" (= "acquired ichthyosis").
Both can be induce by a "drug allergy" but; in practice there is
one important difference: unlike "acquired erythroderma";
"erythrodermic psoriasis" will often
relapse over a lifetime, even if you stop the drug that induced the problem.
Treatment of both diseases is basically the same in a poor hospice...
(See "30-Erythroderma")

Generalized infected "erythrodermic psoriasis / acquired erythroderma" can be an emergency! Patients
are sometimes sent to the hospice because of alarming looking skin diseases
(severe generalized skin edema, fissures of skin because edema, pus...).
However, these patients often still have a high CD4 count and could potentially
live for many more months/years. Treat with dexamethasone IM (4cc morning + 2cc midday + gentamycin 160mg IM daily (+ fluconazole 200 2x/day for prevention of fungal
infection if patient is still able to take it) pxx022-
pxx023-
pxx241-

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